RAILWAY INVESTIGATION REPORT R05T0030 ... Railway Investigation Report Pedestrian Fatality Canadian

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  • RAILWAY INVESTIGATION REPORT R05T0030

    PEDESTRIAN FATALITY CANADIAN NATIONAL FREIGHT TRAIN Q-106-41-15 MILE 124.88, KINGSTON SUBDIVISION BROCKVILLE, ONTARIO 17 FEBRUARY 2005

  • The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

    Railway Investigation Report Pedestrian Fatality Canadian National Freight Train Q-106-41-15 Mile 124.88, Kingston Subdivision Brockville, Ontario 17 February 2005 Report Number R05T0030

    Synopsis On 17 February 2005, at approximately 1515 eastern standard time, Canadian National (CN) freight train Q-106-41-15, proceeding eastward on the CN Kingston Subdivision, struck two pedestrians at the Bartholomew Street public crossing (Mile 124.88), Brockville, Ontario. One pedestrian was fatally injured; the second received serious injuries. The two pedestrians stepped into the path of the eastward train after the passage of a westward train. Ce rapport est également disponible en français.

  • © Minister of Public Works and Government Services Canada 2006 Cat. No. TU3-6/05-1E ISBN 0-662-43984-8

  • TABLE OF CONTENTS

    TRANSPORTATION SAFETY BOARD iii

    1.0 Factual Information ............................................................................ 1 1.1 The Accident .................................................................................................................. 1 1.2 Injuries ............................................................................................................................ 2 1.3 Weather Information..................................................................................................... 2 1.4 Recorded Information................................................................................................... 2 1.5 Train Information .......................................................................................................... 2 1.6 Crew Information.......................................................................................................... 2 1.7 Kingston Subdivision.................................................................................................... 3 1.8 Particulars of the Crossing ........................................................................................... 3 1.9 Behaviour of School Age Pedestrians at Grade Crossings ...................................... 4 1.10 Automatic Warning Devices........................................................................................ 5 1.11 Engine Whistle (Horn) Signal...................................................................................... 6 1.12 Anti-Whistle Authorization for the City of Brockville............................................. 6 1.13 Train Simulation............................................................................................................ 7 1.14 Regulations..................................................................................................................... 7 1.15 Train-Pedestrian Occurrence Statistics....................................................................... 8 1.15.1 Crossing Accident Data................................................................................................ 8 1.15.2 Crossing Type Accident Data ...................................................................................... 9 1.16 Related Crossing Occurrences................................................................................... 11 1.16.1 TSB Occurrence R95D0055, 25 April 1995, Park Street, Brockville, Ontario....... 11 1.16.2 Other Second-Train Events Between 1988 and 2005 Involving Pedestrians....... 11 1.17 Crossing Safety Activities .......................................................................................... 12 1.17.1 Operation Lifesaver..................................................................................................... 12 1.17.2 Transport Canada Railway Safety Research............................................................ 13 1.17.2.1 Research to Assess the Current Use of Second-Train Warning Systems, 1997... 13 1.17.2.2 Research Project Team Established, 1998................................................................. 13 1.17.2.3 Railway Safety Awareness Survey, 1999-2001 ........................................................ 13 1.17.2.4 Research into the Design of Second-Train Warning Signage, 2003...................... 14 1.17.2.5 Research to Develop and Pilot Test a Second-Train Warning System,

    2000-2004...................................................................................................................... 14 1.18 School Proximity to Railway Crossings ................................................................... 15 1.19 Enhanced Crossing Protection in High-Speed, High-Traffic Density Rail

    Corridors...................................................................................................................... 15 1.20 Other Information ....................................................................................................... 17

  • TABLE OF CONTENTS

    iv TRANSPORTATION SAFETY BOARD

    2.0 Analysis.............................................................................................. 19 2.1 Introduction ................................................................................................................. 19 2.2 Common Safety Deficiencies Between Occurrences R95D0055

    and R05T0030 .............................................................................................................. 19 2.2.1 Automatic Warning Devices...................................................................................... 19 2.2.2 Pedestrian Protection at High-Speed, Multi-Track Crossings .............................. 19 2.2.3 Regulations and Standards for Crossing Protection .............................................. 20 2.3 Outcomes of Transport Canada Research into Pedestrian Protection................. 20 2.4 Decision Making by Crossing Users......................................................................... 20 2.5 Pedestrian Sightlines................................................................................................... 21 2.6 Visual Obstruction, Auditory Interference and Pedestrian Behaviour ............... 21 2.7 Timely Response to Deficiency Identification......................................................... 22 2.8 Pedestrian-Specific Crossing Protection .................................................................. 22 2.9 Community Anti-Whistling Bylaw........................................................................... 22

    3.0 Conclusions ....................................................................................... 25 3.1 Findings as to Causes and Contributing Factors .................................................... 25 3.2 Finding as to Risk ........................................................................................................ 25 3.3 Other Finding............................................................................................................... 25

    4.0 Safety Action ..................................................................................... 27 4.1 Action Taken ................................................................................................................ 27 4.1.1 Implementation of Crossing Guards ........................................................................ 27 4.1.2 TSB Rail Safety Advisories......................................................................................... 27 4.1.3 Coroners Inquest Conducted in June 2005 ............................................................. 27 4.2 Action Required........................................................................................................... 29 4.2.1 Implementation of Enhanced Pedestrian Protection.............................................. 29

    Appendices Appendix A Pedestrian Crossing Accidents Involving a Second Train, 1988-2005 ....... 31 Appendix B Preliminary List of Crossings with Potential for Second-Train

    Accidents............................................................................................................. 33 Appendix C List of Brockville Jury Recommendations, 14 June 2005.............................. 45 Appendix D Glossary .............................................................................................................. 49

  • TABLE OF CONTENTS

    TRANSPORTATION SAFETY BOARD v

    Figures Figure 1 South Main Track and East Side of the Street ................................................. 1 Figure 2 Crossing Accident Fatalities Involving Vehicles and Pedestrians............... 9 Figure 3 Crossing Accidents Involving Vehicles by Type of Crossing,

    1996-2005 ............................................................................................................ 10 Figure 4 Crossing Accidents Involving Pedestrians by Type of Crossing, 1996-2005 ............................................................................................................ 10

    Photos Photo 1 View Looking West from Sidewalk in Southeast Quadrant of the

    Bartholomew Street Level Crossing ...........................